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Rahola JT, Mattila SM, Kiviniemi AM, Ukkola OH, Tulppo MP, Junttila MJ, Huikuri HV, Kenttä TV, Perkiömäki JS. Prognostic significance of beat-to-beat variability of spatial heterogeneity of repolarization analyzed from a 5-minute resting electrocardiogram in coronary artery disease. Heart Rhythm 2024:S1547-5271(24)00224-8. [PMID: 38597856 DOI: 10.1016/j.hrthm.2024.02.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Data on the prognostic significance of temporal variability of spatial heterogeneity of electrocardiographic repolarization in coronary artery disease (CAD) are limited. OBJECTIVE The purpose of this study was to evaluate the prognostic value of temporal variability of T-wave morphology analyzed from a 5-minute resting electrocardiogram in CAD. METHODS The standard deviation (SD) of T-wave morphology dispersion (TMD-SD) and the SD of total cosine R-to-T were analyzed on a beat-to-beat basis from a 5-minute period of the standard resting 12-lead electrocardiogram obtained before the clinical stress test in 1702 patients with angiographically verified CAD and well-preserved left ventricular function. RESULTS During an average of 8.7 ± 2.2 years of follow-up, 60 patients experienced sudden cardiac death/arrest (SCD/SCA) (3.5%), 69 patients nonsudden cardiac death (NSCD) (4.1%), and 161 patients noncardiac death (9.5%). TMD-SD was significantly higher in patients who experienced SCD/SCA than in other patients (1.72 ± 2.00 vs 1.12 ± 1.75; P = .01) and higher in patients who succumbed to NSCD than in other patients (1.57 ± 1.74 vs 1.12 ± 1.76; P = .04), but it did not differ significantly between patients who experienced noncardiac death and those without such an event (1.16 ± 1.42 vs 1.14 ± 1.79; P = .86). In the Cox multivariable hazards model, TMD-SD retained its significant association with the risk of SCD/SCA (hazard ratio 1.119; 95% confidence interval 1.015-1.233; P = .024) but not with the risk of NSCD (hazard ratio 1.089; 95% confidence interval 0.983-1.206; P = .103). CONCLUSION TMD-SD is independently associated with the long-term risk of SCD/SCA in patients with CAD.
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Affiliation(s)
- Janne T Rahola
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Severi M Mattila
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Antti M Kiviniemi
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Olavi H Ukkola
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Mikko P Tulppo
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - M Juhani Junttila
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Heikki V Huikuri
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Tuomas V Kenttä
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Juha S Perkiömäki
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland.
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Hekkanen JJ, Kenttä TV, Holmström L, Tulppo MP, Ukkola OH, Pakanen L, Junttila MJ, Huikuri HV, Perkiömäki JS. Association of electrocardiographic spatial heterogeneity of repolarization and spatial heterogeneity of atrial depolarization with left ventricular fibrosis. Europace 2023; 25:820-827. [PMID: 36635858 PMCID: PMC10062366 DOI: 10.1093/europace/euac273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/14/2022] [Indexed: 01/14/2023] Open
Abstract
AIMS To evaluate the relationship between spatial heterogeneity of electrocardiographic repolarization and spatial heterogeneity of atrial depolarization with arrhythmic substrate represented by left ventricular fibrosis. METHODS AND RESULTS We assessed the associations of T- and P-wave morphology parameters analysed from the standard 12-lead electrocardiograms with left ventricular fibrosis in 378 victims of unexpected sudden cardiac death (SCD) who underwent medico-legal autopsy. Based on autopsy findings, the SCD victims were categorized into four different groups according to different stages of severity of left ventricular fibrosis (substantial fibrosis, moderate patchy fibrosis, scattered mild fibrosis, no fibrosis). T-wave and P-wave area dispersion (TWAd: 0.0841 ± 0.496, 0.170 ± 0.492, 0.302 ± 404, 0.296 ± 0.476, P = 0.008; PWAd: 0.574 ± 0.384, 0.561 ± 0.367, 0.654 ± 0.281, 0.717 ± 0.257, P = 0.011, respectively; low values abnormal), non-dipolar components of T-wave and P-wave morphology (T_NonDipolarABS: 0.0496 ± 0.0377, 0.0571 ± 0.0487, 0.0432 ± 0.0476, 0.0380 ± 0.0377, P = 0.027; P_NonDipolarABS: 0.0132 ± 0.0164, 0.0130 ± 0.0135, 0.0092 ± 0.0117, 0.0069 ± 0.00472, P = 0.005, respectively, high values abnormal), T-wave morphology dispersion (TMD: 45.9 ± 28.3, 40.5 ± 25.8, 35.5 ± 24.9, 33.0 ± 24.6, P = 0.030, respectively, high values abnormal), and P-wave heterogeneity (PWH: 20.0 ± 9.44, 19.7 ± 8.87, 17.9 ± 9.78, 15.4 ± 4.60, P = 0.019, respectively, high values abnormal) differed significantly between the groups with different stages of left ventricular fibrosis. After adjustment with heart weight, T_NonDipolarABS [standardized β (sβ) = 0.131, P = 0.014], PWAd (sβ = -0.161, P = 0.003), P_NonDipolarABS (sβ = 0.174, P = 0.001), and PWH (sβ = 0.128, P = 0.015) retained independent association, and TWAd (sβ = -0.091, P = 0.074) and TMD (sβ = 0.097, P = 0.063) tended to retain their association with the degree of myocardial fibrosis. CONCLUSION Our findings suggest that abnormal values of T- and P-wave morphology are associated with arrhythmic substrate represented by ventricular fibrosis partly explaining the mechanism behind their prognostic significance.
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Affiliation(s)
- Jenni J Hekkanen
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Tuomas V Kenttä
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Lauri Holmström
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Mikko P Tulppo
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Olavi H Ukkola
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Lasse Pakanen
- Forensic Medicine Unit, Finnish Institute for Health and Welfare, Hoitajanrinne 1, P.O. Box 310, FI-90101 Oulu, Finland
- Department of Forensic Medicine, Medical Research Center Oulu, Research Unit of Internal Medicine, University of Oulu, Aapistie 5B, P.O. Box 5000, FI-90014 Oulu, Finland
| | - M Juhani Junttila
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Heikki V Huikuri
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Juha S Perkiömäki
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
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Palmieri F, Gomis P, Ruiz JE, Ferreira D, Martín-Yebra A, Pueyo E, Martínez JP, Ramírez J, Laguna P. Nonlinear T-Wave Time Warping-Based Sensing Model for Non-Invasive Personalised Blood Potassium Monitoring in Hemodialysis Patients: A Pilot Study. Sensors (Basel) 2021; 21:s21082710. [PMID: 33921468 PMCID: PMC8069025 DOI: 10.3390/s21082710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/16/2021] [Accepted: 03/30/2021] [Indexed: 11/24/2022]
Abstract
Background: End-stage renal disease patients undergoing hemodialysis (ESRD-HD) therapy are highly susceptible to malignant ventricular arrhythmias caused by undetected potassium concentration ([K+]) variations (Δ[K+]) out of normal ranges. Therefore, a reliable method for continuous, noninvasive monitoring of [K+] is crucial. The morphology of the T-wave in the electrocardiogram (ECG) reflects Δ[K+] and two time-warping-based T-wave morphological parameters, dw and its heart-rate corrected version dw,c, have been shown to reliably track Δ[K+] from the ECG. The aim of this study is to derive polynomial models relating dw and dw,c with Δ[K+], and to test their ability to reliably sense and quantify Δ[K+] values. Methods: 48-hour Holter ECGs and [K+] values from six blood samples were collected from 29 ESRD-HD patients. For every patient, dw and dw,c were computed, and linear, quadratic, and cubic fitting models were derived from them. Then, Spearman’s (ρ) and Pearson’s (r) correlation coefficients, and the estimation error (ed) between Δ[K+] and the corresponding model-estimated values (Δ^[K+]) were calculated. Results and Discussions: Nonlinear models were the most suitable for Δ[K+] estimation, rendering higher Pearson’s correlation (median 0.77 ≤r≤ 0.92) and smaller estimation error (median 0.20 ≤ed≤ 0.43) than the linear model (median 0.76 ≤r≤ 0.86 and 0.30 ≤ed≤ 0.40), even if similar Spearman’s ρ were found across models (median 0.77 ≤ρ≤ 0.83). Conclusion: Results support the use of nonlinear T-wave-based models as Δ[K+] sensors in ESRD-HD patients.
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Affiliation(s)
- Flavio Palmieri
- Centre de Recerca en Enginyeria Biomèdica, Universitat Politècnica de Catalunya, 08028 Barcelona, Spain; (F.P.); (P.G.)
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 50018 Zaragoza, Spain; (A.M.-Y.); (E.P.); (J.P.M.)
- Laboratorios Rubió, Castellbisbal, 08755 Barcelona, Spain;
| | - Pedro Gomis
- Centre de Recerca en Enginyeria Biomèdica, Universitat Politècnica de Catalunya, 08028 Barcelona, Spain; (F.P.); (P.G.)
- Escuela Superior de Ingeniería, Ciencia y Tecnología, Universidad Internacional de Valencia, 46002 Valencia, Spain
| | - José Esteban Ruiz
- Nephrology Ward, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain;
| | - Dina Ferreira
- Laboratorios Rubió, Castellbisbal, 08755 Barcelona, Spain;
| | - Alba Martín-Yebra
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 50018 Zaragoza, Spain; (A.M.-Y.); (E.P.); (J.P.M.)
- BSICoS Group, I3A, IIS Aragón, Universidad de Zaragoza, 50018 Zaragoza, Spain
| | - Esther Pueyo
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 50018 Zaragoza, Spain; (A.M.-Y.); (E.P.); (J.P.M.)
- BSICoS Group, I3A, IIS Aragón, Universidad de Zaragoza, 50018 Zaragoza, Spain
| | - Juan Pablo Martínez
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 50018 Zaragoza, Spain; (A.M.-Y.); (E.P.); (J.P.M.)
- BSICoS Group, I3A, IIS Aragón, Universidad de Zaragoza, 50018 Zaragoza, Spain
| | - Julia Ramírez
- William Harvey Research Institute, Queen Mary University of London, London E1 4NS, UK;
| | - Pablo Laguna
- CIBER en Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 50018 Zaragoza, Spain; (A.M.-Y.); (E.P.); (J.P.M.)
- BSICoS Group, I3A, IIS Aragón, Universidad de Zaragoza, 50018 Zaragoza, Spain
- Correspondence:
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Rahola JT, Kiviniemi AM, Ukkola OH, Tulppo MP, Junttila MJ, Huikuri HV, Kenttä TV, Perkiömäki JS. Temporal variability of T-wave morphology and risk of sudden cardiac death in patients with coronary artery disease. Ann Noninvasive Electrocardiol 2021; 26:e12830. [PMID: 33486851 PMCID: PMC8164143 DOI: 10.1111/anec.12830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 01/04/2021] [Accepted: 01/04/2021] [Indexed: 12/16/2022] Open
Abstract
Background The possible relationship between temporal variability of electrocardiographic spatial heterogeneity of repolarization and the risk of sudden cardiac death (SCD) in patients with coronary artery disease (CAD) is not completely understood. Methods The standard deviation of T‐wave morphology dispersion (TMD‐SD), of QRST angle (QRSTA‐SD), and of T‐wave area dispersion (TW‐Ad‐SD) were analyzed on beat‐to‐beat basis from 10 min period of the baseline electrocardiographic recording in ARTEMIS study patients with angiographically verified CAD. Results After on average of 8.6 ± 2.3 years of follow‐up, a total of 66 of the 1,678 present study subjects (3.9%) had experienced SCD or were resuscitated from sudden cardiac arrest (SCA). TMD‐SD was most closely associated with the risk for SCD and was significantly higher in patients who had experienced SCD/SCA compared with those who remained alive (3.61 ± 2.83 vs. 2.64 ± 2.52, p = .008, respectively), but did not differ significantly between the patients who had experienced non‐SCD (n = 71, 4.2%) and those who remained alive (3.20 ± 2.73 vs. 2.65 ± 2.53, p = .077, respectively) or between the patients who succumbed to non‐cardiac death (n = 164, 9.8%) and those who stayed alive (2.64 ± 2.17 vs. 2.68 ± 2.58, p = .853). After adjustments with relevant clinical risk indicators of SCD/SCA, TMD‐SD still predicted SCD/SCA (HR 1.107, 95% CIs 1.035–1.185, p = .003). Conclusions Temporal variability of electrocardiographic spatial heterogeneity of repolarization represented by TMD‐SD independently predicts long‐term risk of SCD/SCA in patients with CAD.
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Affiliation(s)
- Janne T Rahola
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Antti M Kiviniemi
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Olavi H Ukkola
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Mikko P Tulppo
- Department of Physiology, Research Unit of Biomedicine, Faculty of Medicine, University of Oulu, Oulu, Finland
| | - M Juhani Junttila
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Heikki V Huikuri
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Tuomas V Kenttä
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Juha S Perkiömäki
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
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Isaksen JL, Ghouse J, Graff C, Olesen MS, Holst AG, Pietersen A, Nielsen JB, Skov MW, Kanters JK. Electrocardiographic T-wave morphology and risk of mortality. Int J Cardiol 2020; 328:199-205. [PMID: 33321127 DOI: 10.1016/j.ijcard.2020.12.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/10/2020] [Accepted: 12/02/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Electrocardiographic T-wave morphology is used in drug safety studies as an adjunct to the QTc interval, but few measurements of T-wave morphology can be interpreted in clinical practice. Morphology combination score (MCS) is a combination of T-wave flatness/peakedness, asymmetry, and notching, enabling easy visual assessment of T-wave morphology. We aimed to test the association between T-wave morphology, quantified by MCS, and mortality. METHODS We included electrocardiograms recorded in 2001-2011 from 342,294 primary care patients. Using Cox regression, we evaluated the association between MCS, cardiovascular death, and all-cause mortality, adjusting for heart rate, QTc, QT-prolonging drugs, diabetes, ischemic heart disease, hypertension, and congestive heart failure. RESULTS 270,039 individuals (44% men, median age 55 [inter-quartile range: 42-67 years]) were included and followed for a median of 9.3 years, during which time 13,489 (5.0%) died from cardiovascular causes and 50,481 (18.7%) from any cause. High values of MCS (i.e. asymmetric, flattened, and/or notched T waves) were associated with an adjusted mortality Hazard Ratio of 1.75 (95% CI 1.62-1.89) and 1.61 (1.43-1.92) for women and men, respectively. Low values of MCS (i.e. peaked and symmetric T waves) were associated with a Hazard Ratio of 1.18 (1.08-1.28) and 1.71 (1.48-1.98) for women and men, respectively. CONCLUSIONS In a large primary care population, we found that T-wave asymmetry, flatness, and notching provided prognostic information on mortality independent of heart rate, QTc, and baseline comorbidities.
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Affiliation(s)
- Jonas L Isaksen
- Laboratory of Experimental Cardiology, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jonas Ghouse
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Morten S Olesen
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Anders G Holst
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Adrian Pietersen
- Copenhagen General Practitioners' Laboratory, Copenhagen, Denmark
| | - Jonas B Nielsen
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, University Hospital of Copenhagen, Rigshospitalet, Denmark; Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Morten W Skov
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, University Hospital of Copenhagen, Rigshospitalet, Denmark
| | - Jørgen K Kanters
- Laboratory of Experimental Cardiology, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark.
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Hekkanen JJ, Kenttä TV, Haukilahti MAE, Rahola JT, Holmström L, Vähätalo J, Tulppo MP, Kiviniemi AM, Pakanen L, Ukkola OH, Junttila MJ, Huikuri HV, Perkiömäki JS. Increased Beat-to-Beat Variability of T-Wave Heterogeneity Measured From Standard 12-Lead Electrocardiogram Is Associated With Sudden Cardiac Death: A Case-Control Study. Front Physiol 2020; 11:1045. [PMID: 32982784 PMCID: PMC7477294 DOI: 10.3389/fphys.2020.01045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/29/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction The prognostic significance of beat-to-beat variability of spatial heterogeneity of repolarization measured from standard 12-lead ECG is not well-understood. Methods We measured the short-term variability of repolarization parameters, such as T-wave heterogeneity in leads V4–V6 (TWH) and QT interval (QT), from five consecutive beats of previously recorded standard 12-lead ECG in 200 victims of unexpected sudden cardiac death (SCD) confirmed to be due to complicated atherosclerotic coronary artery disease (CAD) in medico-legal autopsy and 200 age- and sex-matched controls with angiographically confirmed CAD. The short-term variability of repolarization heterogeneity was defined as the standard deviation (SD) of the measured repolarization parameters. All ECGs were in sinus rhythm, and no premature ventricular contractions were included in the measured segment. Results TWH-SD and QT-SD were significantly higher in SCD victims than in subjects with CAD (6.9 ± 5.6 μV vs. 3.8 ± 2.6 μV, p = 1.8E-11; 8.3 ± 13.1 ms vs. 3.8 ± 7.1 ms, p = 0.00003, respectively). After adjusting in the multivariate clinical model with factors, such as diabetes, RR interval, and beta blocker medication, TWH-SD and QT-SD retained their significant power in discriminating between the victims of SCD and the patients with CAD (p = 0.00003, p = 0.006, respectively). TWH-SD outperformed QT-SD in identifying the SCD victims among the study subjects (area under the curve in the receiver operating characteristics curve 0.730 vs. 0.679, respectively). Conclusion Increased short-term variability of repolarization heterogeneity measured from standard 12-lead ECG is associated with SCD.
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Affiliation(s)
- Jenni J Hekkanen
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Tuomas V Kenttä
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Mira Anette E Haukilahti
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Janne T Rahola
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Lauri Holmström
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Juha Vähätalo
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Mikko P Tulppo
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Antti M Kiviniemi
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Lasse Pakanen
- Forensic Medicine Unit, Finnish Institute for Health and Welfare, Oulu, Finland.,Research Unit of Internal Medicine, Department of Forensic Medicine, Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Olavi H Ukkola
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - M Juhani Junttila
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Heikki V Huikuri
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Juha S Perkiömäki
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
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Huang HC, Chien KL, Chang YC, Lin LY, Wang J, Liu YB. Increases in repolarization heterogeneity predict left ventricular systolic dysfunction and response to cardiac resynchronization therapy in patients with left bundle branch block. J Cardiovasc Electrophysiol 2020; 31:1770-1778. [PMID: 32275338 DOI: 10.1111/jce.14488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/30/2020] [Accepted: 04/07/2020] [Indexed: 12/23/2022]
Abstract
INTRODUCTION This study aimed to investigate the association between T-wave morphology and impaired left ventricular ejection fraction (LVEF) in patients with complete left bundle branch block (cLBBB), and the predictive value of T-wave morphology for response to cardiac resynchronization therapy (CRT). METHODS AND RESULTS We enrolled 189 patients with cLBBB on electrocardiogram performed between January 2007 and December 2011 who underwent standard echocardiography. Repolarization parameters, including the QRS-to-T angle (TCRT), T-wave morphology dispersion (TMD), T-wave loop area (PL), and T-wave residuum (TWR), were reconstructed from digital standard 12-lead electrocardiograms by T-wave morphology analysis. CRT response was defined as ≥15% reduction in left ventricular end-systolic volume at 12 months after CRT implantation. The clinical outcome endpoint was a composite of heart failure hospitalization, heart transplantation, or death during follow up (mean, 5.8 years). On logistic regression, a higher heart rate, longer QRS duration, increased TMD, and larger TWR were all independently associated with LVEF < 40%. Among 40 patients who underwent CRT, those with a larger TMD (P = .007), larger PL (P = .025), and more negative TCRT (P = .015) had better response to CRT. A large TMD (P = .018) and large PL (P = .003) were also independent predictors of the clinical outcome endpoint. CONCLUSIONS Increases in repolarization heterogeneity in patients with cLBBB are associated with impaired LVEF. A large TMD and large PL may be useful as additional predictors of response to CRT, improving patient selection for CRT.
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Affiliation(s)
- Hui-Chun Huang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Kuo-Liong Chien
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.,Institute of Epidemiology, College of Public Health, Taipei, Taiwan
| | - Yi-Chung Chang
- Institute of Communication Engineering, National Taiwan University, Taipei, Taiwan
| | - Lian-Yu Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jui Wang
- Institute of Epidemiology, College of Public Health, Taipei, Taiwan
| | - Yen-Bin Liu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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Abstract
BACKGROUND Long QT syndrome type 8 (LQT8) is a rare genotype of long QT syndrome. Late-appearing T-waves (LaT) are often documented in patients with LQT8, as in long QT syndrome type 3 (LQT3); however, the frequency of LaT and its relevance to the clinical severity of LQT8 remains unclear. This study investigated T-wave morphology (TWM) in LQT3 and LQT8 patients and compared the phenotypes of different TWMs.Methods and Results:TWMs were classified into 3 types: early onset T-waves (EoT), LaT, and bifid T-waves (biT). Electrocardiogram (ECG) measurements, symptoms, and topology were compared among TWM types. The study cohort comprised 25 patients with LQT8 (14 mutations) and 25 patients with LQT3 (14 mutations). LaT was detected in 17 (68%) and 13 (52%) LQT8 and LQT3 patients, respectively. There were no significant differences in ECG measurements or the severity of symptoms between patients with LaT and those with other TWMs in either the LQT8 or LQT3 group. However, only patients with LaT experienced cardiopulmonary arrest. Compared with the LQT3 group, in the LQT8 group there was a tendency for mutations in patients with LaT to be located in domain-linking regions. CONCLUSIONS In this study, two-thirds of patients with LQT8 exhibited LaT on ECG, and nearly one-third of those experienced cardiopulmonary arrest. Further investigations are warranted to differentiate between LQT3 and LQT8 in patients exhibiting LaT to optimize therapy.
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Affiliation(s)
- Megumi Fukuyama
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Seiko Ohno
- Department of Bioscience and Genetics, National Cerebral and Cardiovascular Center
| | - Junichi Ozawa
- Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences
| | - Koichi Kato
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Minoru Horie
- Department of Cardiovascular Medicine, Shiga University of Medical Science.,Center for Epidemiologic Research in Asia, Shiga University of Medical Science
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9
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Hnatkova K, Malik M. Sources of QTc variability: Implications for effective ECG monitoring in clinical practice. Ann Noninvasive Electrocardiol 2019; 25:e12730. [PMID: 31760674 PMCID: PMC7358850 DOI: 10.1111/anec.12730] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 10/23/2019] [Indexed: 01/02/2023] Open
Abstract
Pharmaceuticals that prolong ventricular repolarization may be proarrhythmic in susceptible patients. While this fact is well recognized, schemes for sequential QTc interval monitoring in patients receiving QT‐prolonging drugs are frequently overlooked or, if implemented, underutilized in clinical practice. There are several reasons for this gap in day‐to‐day clinical practice. One of these is the perception that serially measured QTc intervals are subject to substantial variability that hampers the distinction between potential proarrhythmic signs and other sources of QTc variability. This review shows that substantial part of the QTc variability can be avoided if more accurate methodology for electrocardiogram collection, measurement, and interpretation is used. Four aspects of such a methodology are discussed. First, advanced methods for QT interval measurement are proposed including suggestion of multilead measurements in problematic recordings such as those in atrial fibrillation patients. Second, serial comparisons of T‐wave morphologies are advocated instead of simple acceptance of historical QTc measurements. Third, the necessity of understanding the pitfalls of heart rate correction is stressed including the necessity of avoiding the Bazett correction in cases of using QTc values for clinical decisions. Finally, the frequently overlooked problem of QT‐heart rate hysteresis is discussed including the possibility of gross QTc errors when correcting the QT interval for simultaneously measured short‐term heart rate.
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Affiliation(s)
| | - Marek Malik
- National Heart and Lung Institute, Imperial College, London, UK
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10
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Ramírez J, van Duijvenboden S, Aung N, Laguna P, Pueyo E, Tinker A, Lambiase PD, Orini M, Munroe PB. Cardiovascular Predictive Value and Genetic Basis of Ventricular Repolarization Dynamics. Circ Arrhythm Electrophysiol 2019; 12:e007549. [PMID: 31607149 DOI: 10.1161/circep.119.007549] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Early prediction of cardiovascular risk in the general population remains an important issue. The T-wave morphology restitution (TMR), an ECG marker quantifying ventricular repolarization dynamics, is strongly associated with cardiovascular mortality in patients with heart failure. Our aim was to evaluate the cardiovascular prognostic value of TMR in a UK middle-aged population and identify any genetic contribution. METHODS We analyzed ECG recordings from 55 222 individuals from a UK middle-aged population undergoing an exercise stress test in UK Biobank (UKB). TMR was used to measure ventricular repolarization dynamics, exposed in this cohort by exercise (TMR during exercise, TMRex) and recovery from exercise (TMR during recovery, TMRrec). The primary end point was cardiovascular events; secondary end points were all-cause mortality, ventricular arrhythmias, and atrial fibrillation with median follow-up of 7 years. Genome-wide association studies for TMRex and TMRrec were performed, and genetic risk scores were derived and tested for association in independent samples from the full UKB cohort (N=360 631). RESULTS A total of 1743 (3.2%) individuals in UKB who underwent the exercise stress test had a cardiovascular event, and TMRrec was significantly associated with cardiovascular events (hazard ratio, 1.11; P=5×10-7), independent of clinical variables and other ECG markers. TMRrec was also associated with all-cause mortality (hazard ratio, 1.10) and ventricular arrhythmias (hazard ratio, 1.16). We identified 12 genetic loci in total for TMRex and TMRrec, of which 9 are associated with another ECG marker. Individuals in the top 20% of the TMRrec genetic risk score were significantly more likely to have a cardiovascular event in the full UKB cohort (18 997, 5.3%) than individuals in the bottom 20% (hazard ratio, 1.07; P=6×10-3). CONCLUSIONS TMR and TMR genetic risk scores are significantly associated with cardiovascular risk in a UK middle-aged population, supporting the hypothesis that increased spatio-temporal heterogeneity of ventricular repolarization is a substrate for cardiovascular risk and the validity of TMR as a cardiovascular risk predictor.
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Affiliation(s)
- Julia Ramírez
- Clinical Pharmacology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry (J.R., S.v.D., A.T., M.O., P.B.M.), Queen Mary University of London, United Kingdom.,Institute of Cardiovascular Science, University College London, United Kingdom (J.R., S.v.D., P.D.L., M.O.)
| | - Stefan van Duijvenboden
- Clinical Pharmacology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry (J.R., S.v.D., A.T., M.O., P.B.M.), Queen Mary University of London, United Kingdom.,Institute of Cardiovascular Science, University College London, United Kingdom (J.R., S.v.D., P.D.L., M.O.)
| | - Nay Aung
- Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute (N.A.), Queen Mary University of London, United Kingdom.,Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (N.A., P.D.L.)
| | - Pablo Laguna
- Biomedical Signal Interpretation and Computational Simulation (BSICoS) group, Aragón Institute of Engineering Research, IIS Aragón, University of Zaragoza, Spain (P.L., E.P.).,Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Spain (P.L., E.P.)
| | - Esther Pueyo
- Biomedical Signal Interpretation and Computational Simulation (BSICoS) group, Aragón Institute of Engineering Research, IIS Aragón, University of Zaragoza, Spain (P.L., E.P.).,Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Spain (P.L., E.P.)
| | - Andrew Tinker
- Clinical Pharmacology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry (J.R., S.v.D., A.T., M.O., P.B.M.), Queen Mary University of London, United Kingdom.,National Institute of Health Research Barts Cardiovascular Biomedical Research Centre, Barts and The London School of Medicine and Dentistry (A.T., P.B.M.), Queen Mary University of London, United Kingdom
| | - Pier D Lambiase
- Institute of Cardiovascular Science, University College London, United Kingdom (J.R., S.v.D., P.D.L., M.O.).,Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (N.A., P.D.L.)
| | - Michele Orini
- Clinical Pharmacology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry (J.R., S.v.D., A.T., M.O., P.B.M.), Queen Mary University of London, United Kingdom.,Institute of Cardiovascular Science, University College London, United Kingdom (J.R., S.v.D., P.D.L., M.O.)
| | - Patricia B Munroe
- Clinical Pharmacology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry (J.R., S.v.D., A.T., M.O., P.B.M.), Queen Mary University of London, United Kingdom.,National Institute of Health Research Barts Cardiovascular Biomedical Research Centre, Barts and The London School of Medicine and Dentistry (A.T., P.B.M.), Queen Mary University of London, United Kingdom
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11
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Pirkola JM, Konttinen M, Kenttä TV, Holmström LTA, Junttila MJ, Ukkola OH, Huikuri HV, Perkiömäki JS. Prognostic value of T-wave morphology parameters in coronary artery disease in current treatment era. Ann Noninvasive Electrocardiol 2018; 23:e12539. [PMID: 29484764 DOI: 10.1111/anec.12539] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 01/10/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The prognostic value of T-wave morphology parameters in coronary artery disease in the current treatment era is not well established. METHODS The Innovation to reduce Cardiovascular Complications of Diabetes at the Intersection (ARTEMIS) study included 1,946 patients with angiographically verified coronary artery disease (CAD). The study patients underwent thorough examinations including 12-lead digital electrocardiogram (ECG) at baseline. RESULTS During a follow-up period of 73 ± 22 months, a total of 201 (10.3%) patients died. Of the study patients, 95 (4.9%) experienced cardiac death (CD) consisting of 44 (2.3%) sudden cardiac deaths (SCD) and 51 (2.6%) nonsudden cardiac deaths (NSCD), and 106 (5.4%) patients experienced noncardiac death (NCD). T-wave morphology dispersion (TMD), T-wave area dispersion (TWAD), and total cosine R-to-T (TCRT) had a significant association with CD even after adjustment with relevant clinical risk markers in the Cox regression analysis (multivariate HRs: 1.015, 95% CI 1.007-1.023, p = .0003; 0.474, 95% CI 0.305-0.737, p = .0009; 0.598, 95% CI 0.412-0.866, p = .006, respectively). When including these parameters to the clinical risk model for CD, the C-index increased from 0.810 to 0.823 improving the discrimination significantly (integrated discrimination index [IDI] = 0.0118, 95% CI 0.0028-0.0208, p = .01). These parameters were more closely associated with NSCD (multivariate p-values from .016 to .001) than with SCD (univariate/multivariate p-values for TMD .015/.197 and for TCRT .012/.43). CONCLUSION T-wave morphology parameters describing repolarization heterogeneity improve the predictive power of the clinical risk model for CD in patients with CAD in the current treatment era.
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Affiliation(s)
- Joni M Pirkola
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Maija Konttinen
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Tuomas V Kenttä
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Lauri T A Holmström
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - M Juhani Junttila
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Olavi H Ukkola
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Heikki V Huikuri
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Juha S Perkiömäki
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
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12
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Favino M, Pozzi S, Pezzuto S, Prinzen FW, Auricchio A, Krause R. Impact of mechanical deformation on pseudo-ECG: a simulation study. Europace 2017; 18:iv77-iv84. [PMID: 28011834 DOI: 10.1093/europace/euw353] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 09/16/2016] [Indexed: 11/12/2022] Open
Abstract
AIMS Electrophysiological simulations may help to investigate causes and possible treatments of ventricular conduction disturbances. Most electrophysiological models do not take into account that the heart moves during the cardiac cycle. We used an electro-mechanical model to study the effect of mechanical deformation on the results of electrophysiological simulations. METHODS AND RESULTS Pseudo-electrocardiogram (ECG) were generated from the propagation of electrical signals in tissue slabs undergoing active mechanical deformation. We used the mono-domain equation for electrophysiology with the Bueno-Orovio ionic model and a fully incompressible Guccione-Costa hyperelastic law for the mechanics with the Nash-Panfilov model for the active force. We compared a purely electrophysiological approach (PE) with mono-directional (MD) and bi-directional (BD) electromechanical coupling strategies. The numerical experiments showed that BD and PE simulations led to different S- and T-waves. Mono-directional simulations generally approximated the BD ones, unless fibres were oriented along one short axis of the slab. When present, notching in the QRS-complex was larger in MD than in BD simulations. CONCLUSIONS Tissue deformation has to be taken into account when estimating the S- and T-wave of the ECG in electrophysiological simulations.
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Affiliation(s)
- Marco Favino
- Center for Computational Medicine in Cardiology, Institute of Computational Science, Università della Svizzera Italiana, Via Giuseppe Buffi 13, Lugano CH-6900, Switzerland;
| | - Sonia Pozzi
- Center for Computational Medicine in Cardiology, Institute of Computational Science, Università della Svizzera Italiana, Via Giuseppe Buffi 13, Lugano CH-6900, Switzerland
| | - Simone Pezzuto
- Center for Computational Medicine in Cardiology, Institute of Computational Science, Università della Svizzera Italiana, Via Giuseppe Buffi 13, Lugano CH-6900, Switzerland
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
| | - Angelo Auricchio
- Center for Computational Medicine in Cardiology, Institute of Computational Science, Università della Svizzera Italiana, Via Giuseppe Buffi 13, Lugano CH-6900, Switzerland.,Division of Cardiology, Fondazione Cardiocentro Ticino, Via Tesserete 48, 6900 Lugano, Switzerland
| | - Rolf Krause
- Center for Computational Medicine in Cardiology, Institute of Computational Science, Università della Svizzera Italiana, Via Giuseppe Buffi 13, Lugano CH-6900, Switzerland
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13
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Abstract
Using BRAVO algorithm (AMPS-LLC, NY, v4.4.0), 5223 ECGs from a publicly available annotated dataset from a randomized clinical trial on four different compounds and placebo were analyzed. ECGs were automatically processed and JTp interval was computed on: 12 standard ECG leads, Vector Magnitude (VM), and root mean square (RMS) leads. On VM and RMS, JTp intervals were nearly identical (228 ± 29 vs. 227 ± 30 ms respectively, with correlation of 0.99, p < 0.0001). On lead II, JTp interval was about 10 ms longer, but highly correlated with that measured on VM (0.94, p < 0.0001). Similarly, on lead V5, JTp was about 8 ms longer than on VM, with a correlation of 0.95, p < 0.0001. When compared to the public available annotations, JTp by BRAVO generated longer (about 8 ms) measurement and evidenced outliers conducible to both the T-wave peak (in few ECGs presenting notched shapes) and, to a lesser degree, to the J point, due to variability of the two algorithms. Differences on the drug-induced effect from the four compounds were negligible.
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14
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Hyltén-Cavallius L, Iepsen EW, Christiansen M, Graff C, Linneberg A, Pedersen O, Holst JJ, Hansen T, Torekov SS, Kanters JK. Glucose ingestion causes cardiac repolarization disturbances in type 1 long QT syndrome patients and healthy subjects. Heart Rhythm 2017; 14:1165-1170. [PMID: 28400316 DOI: 10.1016/j.hrthm.2017.04.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Both hypoglycemia and severe hyperglycemia constitute known risk factors for cardiac repolarization changes potentially leading to malignant arrhythmias. Patients with loss of function mutations in KCNQ1 are characterized by long QT syndrome (LQTS) and may be at increased risk for glucose-induced repolarization disturbances. OBJECTIVE The purpose of this study was to test the hypothesis that KCNQ1 LQTS patients are at particular risk for cardiac repolarization changes during the relative hyperglycemia that occurs after an oral glucose load. METHODS Fourteen KCNQ1 LQTS patients and 28 control participants matched for gender, body mass index, and age underwent a 3-hour oral 75-g glucose tolerance test with ECGs obtained at 7 time points. Fridericia corrected QT interval (QTcF), Bazett corrected QT interval (QTcB), and the Morphology Combination Score (MCS) were calculated. RESULTS QTc and MCS increased in both groups. MCS remained elevated until 150 minutes after glucose ingestion, and the maximal change from baseline was larger among KCNQ1 LQTS patients compared with control subjects (0.28 ± 0.27 vs 0.15 ± 0.13; P <.05). CONCLUSION Relative hyperglycemia induced by ingestion of 75-g glucose caused cardiac repolarization disturbances that were more severe in KCNQ1 LQTS patients compared with control subjects.
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Affiliation(s)
- Louise Hyltén-Cavallius
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Eva W Iepsen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Michael Christiansen
- Department of Clinical Biochemistry, Statens Serum Institut, Copenhagen, Denmark
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Allan Linneberg
- Research Centre for Prevention and Health, The Capital Region, Copenhagen, Denmark; Department of Clinical Experimental Research, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Oluf Pedersen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens J Holst
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Torben Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Signe S Torekov
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jørgen K Kanters
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Cardiology S, Gentofte University Hospital, Copenhagen, Denmark.
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15
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Abstract
Fourteen drugs were removed from the market worldwide because their potential to cause torsade de pointes (torsade), a potentially fatal ventricular arrhythmia. The observation that most drugs that cause torsade block the potassium channel encoded by the human ether-à-go-go related gene (hERG) and prolong the heart rate corrected QT interval (QTc) on the ECG, led to a focus on screening new drugs for their potential to block the hERG potassium channel and prolong QTc. This has been a successful strategy keeping torsadogenic drugs off the market, but has resulted in drugs being dropped from development, sometimes inappropriately. This is because not all drugs that block the hERG potassium channel and prolong QTc cause torsade, sometimes because they block other channels. The regulatory paradigm is evolving to improve proarrhythmic risk prediction. ECG studies can now use exposure-response modeling for assessing the effect of a drug on the QTc in small sample size first-in-human studies. Furthermore, the Comprehensive in vitro Proarrhythmia Assay (CiPA) initiative is developing and validating a new in vitro paradigm for cardiac safety evaluation of new drugs that provides a more accurate and comprehensive mechanistic-based assessment of proarrhythmic potential. Under CiPA, the prediction of proarrhythmic potential will come from in vitro ion channel assessments coupled with an in silico model of the human ventricular myocyte. The preclinical assessment will be checked with an assessment of human phase 1 ECG data to determine if there are unexpected ion channel effects in humans compared to preclinical ion channel data. While there is ongoing validation work, the heart rate corrected J-Tpeak interval is likely to be assessed under CiPA to detect inward current block in presence of hERG potassium channel block.
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Affiliation(s)
- Jose Vicente
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, MD, USA.
| | - Norman Stockbridge
- Division of Cardiovascular and Renal Products, Office of New Drugs, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - David G Strauss
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, MD, USA
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16
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Vedel-Larsen E, Iepsen EW, Lundgren J, Graff C, Struijk JJ, Hansen T, Holst JJ, Madsbad S, Torekov S, Kanters JK. Major rapid weight loss induces changes in cardiac repolarization. J Electrocardiol 2016; 49:467-72. [PMID: 26925492 DOI: 10.1016/j.jelectrocard.2016.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Obesity is associated with increased all-cause mortality, but weight loss may not decrease cardiovascular events. In fact, very low calorie diets have been linked to arrhythmias and sudden death. The QT interval is the standard marker for cardiac repolarization, but T-wave morphology analysis has been suggested as a more sensitive method to identify changes in cardiac repolarization. We examined the effect of a major and rapid weight loss on T-wave morphology. METHODS AND RESULTS Twenty-six individuals had electrocardiograms (ECG) taken before and after eight weeks of weight loss intervention along with plasma measurements of fasting glucose, HbA1c, and potassium. For assessment of cardiac repolarization changes, T-wave Morphology Combination Score (MCS) and ECG intervals: RR, PR, QT, QTcF (Fridericia-corrected QT-interval), and QRS duration were derived. The participants lost on average 13.4% of their bodyweight. MCS, QRS, and RR intervals increased at week 8 (p<0.01), while QTcF and PR intervals were unaffected. Fasting plasma glucose (p<0.001) and HbA1c both decreased at week 8 (p<10(-5)), while plasma potassium was unchanged. MCS but not QTcF was negatively correlated with HbA1c (p<0.001) and fasting plasma glucose (p<0.01). CONCLUSION Rapid weight loss induces changes in cardiac repolarization. Monitoring of MCS during calorie restriction makes it possible to detect repolarization changes with higher discriminative power than the QT-interval during major rapid weight loss interventions. MCS was correlated with decreased HbA1c. Thus, sustained low blood glucose levels may contribute to repolarization changes.
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Affiliation(s)
- Esben Vedel-Larsen
- Laboratory of Experimental Cardiology, Departtment of Biomedical Sciences, University of Copenhagen, Denmark; Danish National Research Foundation Centre for Cardiac Arrhythmia, Denmark; Department of Clinical Neurophysiology, Glostrup Hospital, Denmark
| | - Eva Winning Iepsen
- NNF Center for Basic Metabolic Research, University of Copenhagen, Denmark; Endocrinology Research Section, Department of Biomedical Sciences, University of Copenhagen, Denmark
| | - Julie Lundgren
- NNF Center for Basic Metabolic Research, University of Copenhagen, Denmark; Endocrinology Research Section, Department of Biomedical Sciences, University of Copenhagen, Denmark
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Denmark
| | - Johannes J Struijk
- Department of Health Science and Technology, Aalborg University, Denmark
| | - Torben Hansen
- NNF Center for Basic Metabolic Research, University of Copenhagen, Denmark
| | - Jens Juul Holst
- NNF Center for Basic Metabolic Research, University of Copenhagen, Denmark; Endocrinology Research Section, Department of Biomedical Sciences, University of Copenhagen, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Hvidovre Hospital, Denmark
| | - Signe Torekov
- NNF Center for Basic Metabolic Research, University of Copenhagen, Denmark; Endocrinology Research Section, Department of Biomedical Sciences, University of Copenhagen, Denmark
| | - Jørgen K Kanters
- Laboratory of Experimental Cardiology, Departtment of Biomedical Sciences, University of Copenhagen, Denmark.
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17
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Chorin E, Havakuk O, Adler A, Steinvil A, Rozovski U, van der Werf C, Postema PG, Topaz G, Wilde AAM, Viskin S, Rosso R. Diagnostic value of T-wave morphology changes during "QT stretching" in patients with long QT syndrome. Heart Rhythm 2015; 12:2263-71. [PMID: 26142298 DOI: 10.1016/j.hrthm.2015.06.040] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Specific T-wave patterns on the resting electrocardiogram (ECG) aid in diagnosing long QT syndrome (LQTS) and identifying the specific genotype. However, provocation tests often are required to establish a diagnosis when the QT interval is borderline at rest. OBJECTIVE The purpose of this study was to determine whether T-wave morphology changes provoked by standing aid in the diagnosis of LQTS and determination of the genotype. METHODS The quick-standing test was performed by 100 LQTS patients (40 type 1 [LQT1], 42 type 2 [LQT2], 18 type 3 [LQT3]) and 100 controls. Logistic regression was used to determine whether T-wave morphology changes provoked by standing added to the already established diagnostic value of QTc stretching in identifying LQTS. RESULTS During maximal QT stretching, the T-wave morphologies that best discriminated LQTS from controls included "notched," "late-onset," and "biphasic" T waves. These 3 categories were grouped into a category named "abnormal T-wave response to standing." During quick standing, a QTc stretched ≥490 ms increased the odds of correctly identifying LQTS. T-wave morphology changes provoked by standing were most helpful for identifying LQT2, less helpful for LQT1, and least helpful for LQT3. CONCLUSION The sudden heart rate acceleration produced by abrupt standing not only increases the QTc but also exposes abnormal T waves that are valuable for diagnosing LQTS.
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Affiliation(s)
- Ehud Chorin
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofer Havakuk
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arnon Adler
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arie Steinvil
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Rozovski
- Department of Internal Medicine, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Christian van der Werf
- Heart Center, Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Pieter G Postema
- Heart Center, Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Guy Topaz
- Department of Internal Medicine, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arthur A M Wilde
- Heart Center, Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Sami Viskin
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Raphael Rosso
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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18
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Abstract
Athletic intensive exercise is associated with repolarization changes affecting the ST-segment and T-wave morphology. The prevalence and distribution of these alterations are influenced by several demographic factors. One of the most challenging conundrums for both the cardiologist and the sports medicine physician is the correct interpretation of these repolarization changes to prevent an erroneous diagnosis with potentially serious consequences. A 12-lead electrocardiogram (ECG) demonstrating inverted T-waves may represent the first and only sign of such inherited heart muscle diseases, and may precede the detection of any structural changes in the heart, however, T-wave inversion in leads V1-V4 in black athletes may represent ethnic variation which is exaggerated by exercise.
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Affiliation(s)
- Ricardo Stein
- Universidade Federal do Rio Grande do Sul, Cardiology Division, and Exercise Cardiology Research Group (CardioEx), Vitta Centro de Bem Estar Físico, Porto Alegre, Brazil.
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19
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Abstract
Although the scientific literature contains ample descriptions of peculiar patterns of repolarization linked to arrhythmic risk, the objective quantification and classification of these patterns continues to be a challenge that impacts their widespread adoption in clinical practice. To advance the science, computerized algorithms spawned in the academic environment have been essential in order to find, extract and measure these patterns. However, outside the strict control of a core lab, these algorithms are exposed to poor quality signals and need to be effective in the presence of different forms of noise that can either obscure or mimic the T-wave variation (TWV) of interest. To provide a practical solution that can be verified and validated for the market, important tradeoffs need to be made that are based on an intimate understanding of the end-user as well as the key characteristics of either the signal or the noise that can be used by the signal processing engineer to best differentiate them. To illustrate this, two contemporary medical devices used for quantifying T-wave variation are presented, including the modified moving average (MMA) for the detection of T-wave Alternans (TWA) and the quantification of T-wave shape as inputs to the Morphology Combination Score (MCS) for the trending of drug-induced repolarization abnormalities.
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Wang F, Liu J, Hong L, Liang B, Graff C, Yang Y, Christiansen M, Olesen SP, Zhang L, Kanters JK. The phenotype characteristics of type 13 long QT syndrome with mutation in KCNJ5 (Kir3.4-G387R). Heart Rhythm 2013; 10:1500-6. [PMID: 23872692 DOI: 10.1016/j.hrthm.2013.07.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND Long QT syndrome type 13 (LQT13) is caused by loss-of-function mutation in the KCNJ5-encoded cardiac G-protein-coupled inward rectifier potassium channel subtype 4 protein. The electrocardiographic (ECG) features of LQT13 are not described yet. OBJECTIVE To describe for the first time in detail the phenotype-genotype relationship of the ECG and clinical features in patients with LQT13. METHODS The 12-lead ECGs, 24-hour Holter recordings, and clinical information from KCNJ5-G387R mutation carriers of a fourth-generation Han Chinese family with LQT13 and a group of healthy Chinese individuals were analyzed. RESULTS Compared with the analysis of the healthy group (n = 8), age- and sex-matched pair analysis revealed that the mutation carriers (n = 8) had ventricular repolarization abnormality results in the prolongation of corrected QT and QTpeak intervals (P < .01); greater combined measure of repolarization morphology (T-wave morphology combination score) based on asymmetry, flatness, and notch (P < .01); and reduced low frequency/high frequency ratio of heart rate variability (P < .01) as a reflection of cardiac autonomic imbalance. Mean heart rate, time domain parameters of heart rate variability, time interval from T-wave peak to T-wave end, and T-wave amplitude were similar. CONCLUSIONS This study demonstrates for the first time the ECG features of patients with LQT13. Our data suggest that QTpeak intervals and T-wave morphology combination score may be the better parameters than the corrected QT interval to predict the phenotype-genotype relationship in patients with LQT13.
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